198603286-7-30-2021-28-AS-TVAO-CYAPA6-20231207100809

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 07/30/2021
Date Signed: 07/30/2021 01:38:45 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/25/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210525125201

FACILITY NAME:	PASADENA VILLA SENIOR LIVING		FACILITY NUMBER:	198603286
ADMINISTRATOR:	MURPHY, MICHAEL		FACILITY TYPE:	740
ADDRESS:	1811 N. RAYMOND AVE		TELEPHONE:	(626) 791-6232
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY:	97	CENSUS: 39	DATE:	07/30/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Alex Solorio, assistant administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility is not ensuring resident obtains necessary medical equipment.
Resident's call light is not functioning.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegations listed above. LPA Spencer was met by assistant administrator Alex Solorio and explained the purpose of today's visit.

The investigation consisted of the following: On 5/26/21, LPA Spencer conducted a health & safety check and obtained copies of the staff and resident roster. On 7/30/21, LPA Spencer interviewed the assistant administrator, staff #1-2 (S1-S2), and residents #1-3 (R1-R3). R4 was not at the facility and was unable to be reached by phone after several attempts. LPA Spencer collected copies R4's face sheet, physician's report, call light pendant acknowledgement form, hospital bed order form, and discharge papers.

The investigation revealed the following: regarding allegation facility is not ensuring resident obtains necessary medical equipment, it was alleged the the facility did not ensure that a resident was provided with a hospital bed. ***Narrative continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210525125201

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
	VISIT DATE: 07/30/2021

NARRATIVE

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On today's visit on 7/30/21, LPA observed that R4's room had a hospital bed with half rails. LPA reviewed the hospital bed order form showing that the hospital bed was ordered on 4/30/21 and arrived to the facility on 5/3/21. The administrator stated that the bed was assembled but had full rails so it had to be adjusted/replaced with half rails. All staff interviewed stated that the facility provides accommodations for hospital beds and that no residents have complained about not receiving necessary medical equipment. R1-R3 stated that they use hospital beds and they have no issues with the facility obtaining necessary medical equipment for residents.

Regarding the allegation that resident's call light is not functioning, LPA observed that R4's room had a functioning call light. LPA reviewed call light pendant acknowledgement forms that showed that R4 received a replacement call light on 5/26/21 and 6/2/21. Per interview with assistant administrator, each resident receives a call light pendant. If the call light stops working or residents misplace it, it is replaced by the facility once staff are made aware and the resident signs for the replacement. Assistant administrator stated that R4 has received 3-4 call light pendant replacements due to being misplaced or not functioning. All staff interviewed stated that call light pendants are replaced right away if they're not functioning. R1-R3 stated that they have a functioning call light and demonstrated that they were functional.

Based on observations, interviews, and record reviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted, and a copy of report was provided to Assistant Administrator.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

LIC9099 (FAS) - (06/04)

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